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Highlights

H1N1 studies offer insight into potential pandemics' presentation

Studies from around the globe are offering initial glimpses into who might be at increased risk during a potential H1N1 influenza pandemic and how the disease course for the sickest patients might strain available hospital resources.

Three studies from Journal of the American Medical Association reported on the effects of H1N1 in Australia/New Zealand, Canada and Mexico. Generally, reports considered what course illness took in these regions and found that:

the median patient age was 30s or 40s,

patients were frequently obese, or had other complications,

patients were ill for four to seven days before going to the hospital,

once patients were admitted to the hospital, severe cases quickly went to the ICU,

severe hypoxemia progressed to shock or multiple organ failures, and

cases of severe respiratory illness refractory to conventional mechanical ventilation had been managed with extracorporeal mechanical oxygenation (ECMO) for a median of 12 days.

In the report of the H1N1 pandemic in Australia and New Zealand, 68 patients required ECMO, representing one-third of all patients who'd been mechanically ventilated. The average age of patients who got ECMO was 34 years, with the most common comorbidities being obesity, asthma and diabetes. Six patients were pregnant and four were post-partum. Fourteen of the 68 died. In Australia and New Zealand, only 15 of the nearly 200 ICUs have ECMO available, and the number of days on ECMO created a substantial burden during the weeks-long peak period of the outbreak, authors reported. Rough estimates are that 800 Americans and 1,300 European Union residents might require ECMO this flu season if managed as was done in Australia and New Zealand.

In Canada, researchers reported on 168 critically ill patients. The mean age was 32 years, with an overall mortality of 14.3% at 28 days and 17.3% at 90 days. All the patients were severely hypoxemic, and shock and acute organ dysfunction were common. Mechanical ventilation was required by 136 patients, with a median of 12 days' duration.

In Mexico, researchers reported on 58 patients admitted to the hospital with critical illness. The median patient age was 44 years. In the study, 54 of the 58 required mechanical ventilation. By 60 days, 24 patients had died, and those patients were more likely to have had greater initial severity, worse hypoxemia, higher creatinine kinase levels, higher creatinine levels and ongoing organ dysfunction. Because of increased patient volumes during the disease peak, ICU admission was delayed and four patients died in the ED.

Survival will depend on how physicians and hospitals apply mechanical ventilation and rescue therapies, and many hospitals lack the expertise, according to an accompanying editorial.

In the U.S., health officials now say that 46% of 1,400 adults hospitalized with H1N1 influenza did not have a chronic underlying condition, according to the largest analysis to date.

The study looked at adults and children hospitalized from April through August in 10 states at medical centers participating in a special disease surveillance network. Anne Schuchat, FACP, who heads the CDC's National Center for Immunization and Respiratory Diseases, said the larger analysis looked at underlying conditions not previously examined. Among adults, 26% had asthma, 10% had diabetes, 8% had some other chronic lung disease, 8% had weakened immune systems and 6% were pregnant.

A Michigan study found that severe H1N1 influenza placed patients at risk of pulmonary embolism. Researchers based at the University of Michigan examined the medical condition of 66 patients diagnosed with H1N1 influenza. Of these, 14 patients were severely ill and were admitted to the ICU. CT scans identified PE in five cases. Results were reported online by the American Journal of Roentgenology.

DENVER—The recession has caused medical practice revenue to decline for the first time in several years, according to data released at the Medical Group Management Association's annual meeting.

MGMA's cost survey found a 1.9% decrease between 2007 and 2008 in total medical revenue for multispecialty groups. A likely explanation for this decrease was the 9.9% drop in patient procedures and 11.3% decrease in the number of patients that the survey participants recorded between 2006 and 2008. The survey also found a 13% increase in bad debt. More than a third of MGMA members reported seeing a rise in uninsured patients.

Medical practices also took a number of actions in response to the recession, the survey found. Overall, overhead expenses declined by 1.4%. Support staff costs went down by 1.5% although the number of staff remained stable, indicating that practices may have forgone raises and bonuses and even instituted pay cuts. More than a third of surveyed MGMA members reported hiring freezes, postponed capital expenditures, cuts to operating budgets and improved billing and collections processes.

Despite the hiring freezes, MGMA's member survey data found an overall trend toward an increase in the size of medical practices. Between 2003 and 2008, the average number of physicians in a physician-owned practice grew from 16.4 to 18.8, while the average in hospital-owned groups rose from 64.3 to 76.3. "It reinforces that the trend in the industry is toward consolidation," said MGMA president William F. Jessee, MD.

For the second time ever, MGMA also surveyed its members about their attitudes toward payers. More than 1,700 practice administrators offered their perceptions about interactions with seven major national payers, including credentialing, contracting, payment policies and overall satisfaction. Medicare Part B was ranked highest for overall satisfaction, followed by Aetna and CIGNA. "The rules are clear for Medicare," noted Dr. Jessee, although he added that provider credentialing remains a major issue.

Test yourself

MKSAP Quiz: worsening dyspnea and exercise intolerance

A 64-year-old man is evaluated for worsening dyspnea and a gradual decrease in exercise tolerance over the past 2 months associated with his chronic obstructive pulmonary disease. He had an acute coronary syndrome 2 years ago, and his medications include daily aspirin, bronchodilators, inhaled corticosteroids, atenolol, and a statin.

End-of-life care

Elderly on dialysis face likely functional decline

Starting dialysis is associated with substantial functional decline in elderly people with end-stage renal disease (ESRD), a new study found.

Researchers used a national registry to identify all 3,702 nursing home residents in the U.S. who began dialysis between June 1998 and October 2000. Measurements of functional status (specifically, dependence in activities of daily living) were compared before and after the initiation of treatment. At three months, the median functional status score had increased and 39% of patients had maintained their level of function. After a year, however, 58% of the studied patients had died and only 13% of them had maintained the function they had before dialysis.

Some coexisting conditions, including cerebrovascular disease, dementia and hospitalization at the start of dialysis, were associated with reduced odds of maintaining function. Researchers noted that these conditions and the high general prevalence of disability among these patients cannot be corrected by dialysis. In fact, the benefits of correcting uremia may be outweighed by the physical and psychosocial burden of therapy, the authors speculated.

They suggested that provision of dialysis in inpatient settings could reduce the burden on the patient and that efforts should be made to address the goals of care, alleviate suffering and maintain function even before the initiation of dialysis. The results of this study could be used to help inform discussions about dialysis with elderly ESRD patients, the study authors said. Elderly patients should be informed about the modest benefits of dialysis observed in their age group, agreed an accompanying editorial, which also called for clinicians to present conservative therapy as a clear option, not a last resort.

The study was published in the Oct. 15 New England Journal of Medicine. The dilemma of when to provide dialysis to the very elderly was covered in the Sept. 2007 ACP Observer (now ACP Internist).

Patients with advanced dementia were less likely to undergo interventions near the end of life if their families and caregivers understood the patients' prognoses and likely complications, a recent study found.

Researchers followed 323 residents of nursing homes with advanced dementia and their health care proxies for 18 months. By the end of the study period, 54.8% of patients died and many experienced complications, including pneumonia (41.1%), febrile episodes (52.6%) and eating problems (85.8%). Almost 41% of residents underwent interventions such as hospitalization or tube feeding during the last three months of life, but interventions were less likely among patients whose proxies had an understanding of the prognosis and expected complications of dementia. The results appear in the Oct. 15 New England Journal of Medicine.

The findings can be used to inform families that infections and eating problems should be expected in patients with advanced dementia and that they often signal imminent death, the authors said. The study also underscores that while these complications may precede death, dementia is the underlying cause.

Knowing that certain complications are associated with high rates of death within six months gives families and caregivers time to discuss the goals of care and potential hospice referral, said an accompanying editorial. The findings highlight that advanced dementia is a terminal illness that requires palliative care, the editorial continued, and that patients with advanced dementia do not need to have another serious illness to qualify for hospice care.

Discussions of the issues raised in the study by providers and families have the potential to modify the perceptions of health care proxies and affect their decisions about the use of interventions and hospice care, the editorial said. The findings should also inform public policy decisions about hospice and trigger funding for research on the use of palliative care and improving current systems of care.

Women's health

Women who experience breast tenderness after starting combined hormone therapy may have a higher risk of developing breast cancer, according to a new analysis of the Women’s Health Initiative.

Researchers analyzed data from the WHI estrogen plus progestin trial in which postmenopausal women were randomized to receive either daily conjugated equine estrogens plus medroxyprogesterone or placebo. Of the more than 14,000 women without breast tenderness at baseline, 36.1% in the combined therapy group reported breast tenderness after 12 months, compared with 11.8% in the placebo group. Among women in the combined therapy group, breast cancer risk was significantly higher in those with new-onset breast tenderness than in those without. The study appears in the Oct. 12 Archives of Internal Medicine.

The predictive value of new-onset breast tenderness in women taking hormone therapy is similar to the Gail model, which considers patient age, age at menarche, previous breast biopsies, family history of breast cancer, and parity, the authors noted. Based on a mean follow-up of 5.6 years, new-onset breast tenderness had a sensitivity of 41%, a specificity of 64% and a positive predictive value of 2.7% for predicting invasive breast cancer.

The WHI trial previously demonstrated that combined hormone therapy increases breast cancer risk, mammographic density and frequency of abnormal mammograms, the authors noted. This study identifies a potentially high-risk population and should inform discussions between physicians and patients about whether to continue combined hormone therapy after a woman experiences breast tenderness, they said.

Men's health

Minimally invasive prostatectomy not better just because it's high-tech

Minimally invasive radical prostatectomy (MIRP) isn't better just because it's high-tech, authors cautioned in comparing the surgery, which is often robot-assisted, to the gold standard of retropubic radical prostatectomy (RRP).

Use of MIRP increased fivefold from 9.2% in 2003 to 43.2% in 2006-2007. Use of robotic-assisted MIRP increased from 1% to 40% of all radical prostatectomies from 2001 to 2006. Patients may see minimally invasive, high-tech approaches as a way to reduce complications, pain or length of stay, despite a lack of evidence, authors suggested.

To compare the effectiveness of MIRP with RRP, researchers conducted a population-based observational cohort study using Medicare data from 2003 through 2007. They reported results in the Oct. 14 Journal of the American Medical Association.

The authors noted that RRP is performed through a relatively small incision, infrequently is associated with significant pain, and averages a one- to three-day length of stay at high-volume referral centers.

The authors concluded, "In light of the mixed outcomes associated with MIRP, our finding that men of higher socioeconomic status opted for a high-technology alternative despite insufficient data demonstrating superiority over an established gold standard may be a reflection of a society and health care system enamored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption."

Quality improvement

Hospital to Home project launches

The American College of Cardiology and the Institute for Healthcare Improvement will launch their joint Hospital to Home (H2H) initiative tomorrow.

The national quality improvement project, for which ACP is a strategic partner, aims to improve inpatient to outpatient transitions in patients with cardiovascular disease. Its goal is to achieve a 20% reduction in 30-day all-cause hospital readmission rates for patients with heart failure or acute myocardial infarction by December 2012. The initiative will focus on three main areas: medication management post-discharge, early follow-up and symptom management.

H2H will launch with a kickoff Webinar on Oct. 22 at 1 p.m. ET. More information is available online.

The September 2009 ACP Hospitalist included an interview with John Rumsfeld, FACP, co-chair of the H2H quality initiative.

Health care reform

Senate attempts to repeal the SGR

The Senate announced to ACP and other physician organizations that it would consider legislation to repeal the sustainable growth rate (SGR) formula used to calculate Medicare payments.

The SGR formula ties Medicare payments to growth of the country’s overall economy. Using the formula has resulted in physicians being forced each year to fight to prevent large cuts in their Medicare payments. The legislation being considered, the “Medicare Physicians Fairness Act of 2009” (S. 1776), would permanently eliminate the use of the SGR formula. Further action would still need to be taken to establish a new system of updating Medicare payments.

A preliminary vote to allow the bill to proceed outside the normal budget rules is expected on Tuesday. Please visit ACP’s Legislative Action Center for instructions on how you can encourage your senators to vote for this legislation.

Information technology

National eHealth Collaborative hosts forums tomorrow

The National eHealth Collaborative (NeHC) will host a series of interactive discussion forums with experts and stakeholders on Oct. 21. Topics include “Bedside to Bench: How Health IT Can Power Better Clinical Research” and “The Backbone of the Healthcare System: Nurses' Critical Role in HIT Implementation.” ACP’s Executive Vice President and Chief Executive Officer, John Tooker, FACP, chairs the organization’s board of directors. The forum is available both in person and online, 9 a.m. to 12:30 p.m. ET.

From the College

Call for spring 2010 Board of Governors Resolutions

The deadline for submitting new resolutions to be heard at the April 2010 Board of Governors Meeting is Friday, Dec. 18, 2009. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. Members must submit resolutions to their Governor and/or chapter council. A resolution becomes a resolution of the chapter once the chapter council approves it.

In accordance with the ACP Board of Governors Resolutions Process, a resolution should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy …”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents …”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.

The Board of Governors votes on new resolutions, which are then presented to the Board of Regents for action. Members can use the Electronic Resolutions System (ERS) to monitor the status of resolutions. Visit your chapter Web site and link to the ERS under the "Advocacy" heading.

National Primary Care Week highlights importance of primary care

This week marks National Primary Care Week (NPCW), an annual event highlighting the importance of primary care. Health care professionals come together for the event to discuss and learn about generalist and interdisciplinary health care, and particularly its impact on and importance to underserved populations. NPCW aims to focus the attention of health professional students from all disciplines on the failure of the health care system to provide equal, high-quality health care to all individuals, regardless of ethnicity, race and other factors, and to provide students with the tools to address these inequalities. “Primary Care Is Everybody Care: The Future of Medicine Is Now” takes place October 19-23, and is a collaboration of the American Medical Student Association and Student Osteopathic Medical Association chapters. More information is available online.

ACP issues guideline on drugs for ED

ACP today issued a guideline on recommendations for the treatment of erectile dysfunction (ED). ACP recommends that physicians treat patients seeking treatment for ED with an oral PDE-5 inhibitor if no contraindications to such medications exist. Results from randomized, controlled trials showed that treatment with a PDE-5 inhibitor resulted in statistically significant and clinically relevant improvements in sexual intercourse and erectile function in patients with ED, regardless of cause. ACP also recommended that the choice between various PDE-5 inhibitors should be based on patient preference regarding ease of use, cost, and adverse effects. Overall, evidence indicated the PDE-5 inhibitors to be well tolerated with only mild to moderate side effects. The evidence was insufficient regarding the benefit of routine measurement of hormone levels or hormonal treatment in patients with ED.

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries by October 22. This issue, a guest judge, John Reed, FACP, the winner of two previous contests, will choose three finalists who will be posted in the Oct. 27 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the Nov. 3 edition.

This patient has iron-deficiency anemia, most likely resulting from chronic gastric bleeding. He requires iron-replacement therapy, not blood transfusion, in addition to careful monitoring and follow-up. The response to oral iron is fast, with a response in this patient likely to occur in less than a week. There is no evidence of malabsorption in this patient; therefore, intravenous iron is not indicated.

This patient's chronic dyspnea is due to poor lung function and not a lack of oxygen-carrying capacity. There is little evidence that increased circulating red cell mass at his current hemoglobin will improve tissue oxygenation in pulmonary disease. In the intensive care setting, a liberal transfusion strategy to a target hemoglobin of 10 to 12 g/dL (100 to 120 g/L) in euvolemic patients was associated with a higher overall mortality rate when compared with a restrictive transfusion strategy to a target level of 7 to 9 g/dL (70 to 90 g/L). This adverse effect of the higher hemoglobin may occur because the higher hematocrit increases viscosity and, consequently, impairs capillary blood flow. The patient's cardiac history is not a reason to institute blood transfusion. If he were having an acute ischemic event, some studies suggest transfusion is desirable to increase hematocrit to >30%, but even this approach has been questioned recently.

This patient's signs, symptoms, and laboratory findings are not suggestive of renal disease, which might cause a low erythropoietin level, or a bone marrow disorder, which would require administration of supraphysiologic levels of erythropoietin. Moreover, erythropoietin therapy would be ineffective in this patient until iron has become available for red blood cell production.

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Copyright 2009 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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